Diagnosis of sleep apnea in patients with stable chronic heart failure using a portable sleep test diagnostic device.

PURPOSE: ApneaLink is a portable device for the screening of sleep apnea, a prevalent and underdiagnosed comorbidity in heart failure patients. A prospective cross-sectional study in patients with chronic heart failure was carried out to assess the sensitivity and specificity of apnea-hypopnea index (AHI) measurements using ApneaLink against the standard polysomnography test. METHODS: Adult patients with a prior hospitalization in an acute heart failure hospital unit were recruited for the study. All participants were tested for sleep apnea using ApneaLink and polysomnography simultaneously during an overnight stay at a sleep laboratory. Global sleep apnea was evaluated according to the AHI, which was analyzed and compared. Subpopulation comparison based on ejection fraction was not realized due to population size. RESULTS: Thirty-five patients with stable chronic heart failure completed the study (mean age 70.9 ± 10.5 years and body mass index 30.0 ± 4.7 kg/m2). Two patients were excluded due to insufficient study duration. ApneaLink had a sensitivity greater than 80% for all AHI measurements, and a specificity greater than 80% for all AHI measurements, except for AHI ≥ 5 events/h (61.5%). The results showed higher sensitivities and specificities at AHI values of ≥ 10 events/h (sensitivity 81.3% and specificity 84.2%) and ≥ 15 events/h (sensitivity 83.3% and specificity 91.3%). Correlation analysis showed that AHI measurements using ApneaLink and polysomnography had a strong and significant correlation (r = 0.794; P < 0.001). CONCLUSIONS: Our results suggest that ApneaLink could be used in clinical practice to identify heart failure patients with high (AHI ≥ 15 events/h) and low (AHI < 5 events/h) probability of having sleep apnea, sparing the need for a diagnostic polysomnography and thus potentially impacting prognosis by providing a more cost-effective and timely diagnosis of this non-cardiac comorbidity.

Pulmonary Kaposi's sarcoma-an atypical clinical presentation.

HIV-associated Kaposi's sarcoma is an angioproliferative neoplasia caused by infection with human herpesvirus 8. It typically presents with mucocutaneous involvement. Pulmonary Kaposi's sarcoma is rare, and an uncommon form of initial presentation of the disease. The authors present the clinical case of an HIV-positive patient with Kaposi's sarcoma who had exclusively pulmonary involvement at diagnosis. This case is highlighted for its rarity, by the diagnostic challenge it presented, and for the important role of bronchoscopy as a diagnostic tool for this pathology. Bronchoscopy allows direct visualization of the lesions and the ability to perform a bronchoalveolar lavage and directed biopsies.

Spontaneous pneumomediastinum, a rare manifestation of clinically amyopathic dermatomyositis.

Clinically amyopathic dermatomyositis (CADM) is a rare condition characterized by dermatomyositis skin lesions without clinically apparent muscle involvement. Respiratory involvement is common, occurring in about half of the cases. Spontaneous pneumomediastinum (PnM) is a rare, and often fatal, complication of CADM. We report a case of a 61-year-old female patient who was diagnosed with anti-melanoma differentiation- associated gene 5 antibody-associated CADM and interstitial lung disease. She developed an extensive spontaneous PnM with subcutaneous emphysema. The patient was treated with a conservative approach which was, initially, successful in reducing the size of the PnM. However, the patient died from an eventual nosocomial pneumonia requiring mechanical ventilation. This case illustrates that improving the management of CADM associated PnM, remains a major unmet need.

Use of Brentuximab Vedotin in a Non-HIV Patient with Primary Effusion Lymphoma.

Primary effusion lymphoma is a rare and aggressive large B-cell lymphoma presenting as malignant effusion with poor prognosis. Although it is more prevalent among HIV patients, it has also been described in non-HIV immunocompromised individuals. Given its rarity, there are no large randomized trials regarding the best therapeutic option. The choice of therapy is based on retrospective studies, case reports and preclinical data. We present the case of a non-HIV patient with relapsed disease after treatment with CHOP who was then successfully treated with brentuximab vedotin, achieving complete remission. LEARNING POINTS: Primary effusion lymphoma is a rare entity in non-HIV patients, so there are no clinical trials regarding therapeutic options or management decisions.Targeted therapy with brentuximab vedotin has been used in other CD30 positive malignancies and in HIV-related primary effusion lymphoma with good outcomes.We present the case of a non-HIV patient with primary effusion lymphoma who was successfully treated with brentuximab vedotin, which highlights the potential role of a new therapeutic approach in this subgroup of patients.

[Wegener's granulomatosis - a case report]. / granulomatose de Wegener-a propósito de um caso clínico.

The Wegener granulomatosis (WG) is a rare vasculite which involves preferentially the upper airways, lungs and kidneys, although it can presents in a multissistemic form. The authors present a clinical case of WG, its diagnostic methodology and respective follow-up from de last two years and half. There are discussed the most often presentation forms of the disease, the importance of histologic results and the contribution of ANCA's determination for disease diagnosis and follow-up. Although important, the histological results, are not essential for WG diagnosis, since clinic presentation and immunological data (ANCA's) are suggestive of the disease. Airways infections and ANCA's presence seems to be important in the etiopathogenesis of WG.

[Emphysema and lung volume reduction surgery--a case report]. / Enfisema pulmonar e cirurgia de redução de volume - a propósito de um caso clínico.

Lung volume reduction surgery (LVRS) has been proposed as a palliative therapy in severe emphysema, with good results in lung function improvement, exercise capacity and quality of life. The authors present a case report of a 34 years old man with severe, heterogeneous lung emphysema submit to bilateral LVRS in 2000 January. Pre-surgical conditions, clinical and radiological evolution after surgery and for a 30 months follow up were analysed. Based on a literature revision, some technical aspects of LVRS, selection criteria and comparative study of medical and surgical therapy were discussed.

Insights into the relationship between antimicrobial residues and bacterial populations in a hospital-urban wastewater treatment plant system.

The relationship between antimicrobial residues, antibiotic resistance prevalence and bacterial community composition in hospital effluent and in the receiving wastewater treatment plant was studied. Samples from hospital effluent, raw inflow and final effluent of the receiving wastewater treatment plant were characterized for amoxicillin and ciprofloxacin resistance prevalence, content of heavy metals and antimicrobial residues and bacterial community structure, based on 16S rRNA gene PCR-DGGE analysis. The concentration of fluoroquinolones, arsenic and mercury was in general higher in hospital effluent than in raw inflow, while the opposite was observed for tetracyclines, sulfonamides and penicillin G. The prevalence of ciprofloxacin resistance was significantly higher in hospital effluent than in raw inflow. The concentration of antimicrobial residues was observed to be significantly correlated with the prevalence of antibiotic resistant bacteria and with variations in the bacterial community. Hospital effluent was confirmed as a relevant, although not unique, source of antimicrobial residues and antibiotic resistant bacteria to the wastewater treatment plant. Moreover, given the high loads of antibiotic residues and antibiotic resistant bacteria that may occur in hospital effluents, these wastewater habitats may represent useful models to study and predict the impact of antibiotic residues on bacterial communities.

Antibiotic resistance, antimicrobial residues and bacterial community composition in urban wastewater.

This study was based on the hypothesis that the occurrence of antimicrobial residues and antibiotic resistant bacteria in the sewage could be correlated with the structure and composition of the bacterial community and the antibiotic resistance loads of the final effluent. Raw and treated wastewater composite samples were collected from an urban treatment plant over 14 sampling dates. Samples were characterized for the i) occurrence of tetracyclines, penicillins, sulfonamides, quinolones, triclosan, arsenic, cadmium, lead, chromium and mercury; ii) antibiotic resistance percentages for tetracycline, sulfamethoxazole, ciprofloxacin and amoxicillin and iii) 16S rRNA gene-DGGE patterns. The data of corresponding samples, taking into account the hydraulic residence time, was analyzed using multivariate analysis. Variations on the bacterial community structure of the final effluent were significantly correlated with the occurrence of tetracyclines, penicillins, sulfonamides, quinolones and triclosan in the raw inflow. Members of the class Epsilonproteobacteria presented positive correlations with those antimicrobials, whereas negative correlations were observed with Beta and Gammaproteobacteria and Firmicutes. Antibiotic resistance percentages presented different trends of variation in heterotrophs/enterobacteria and in enterococci, varied over time and after wastewater treatment. Antibiotic resistance was positively correlated with the occurrence of tetracyclines residues and high temperature. A relationship between antibiotic residues, bacterial community structure and composition and antibiotic resistance is demonstrated. Further studies, involving more wastewater treatment plants may help to elucidate this complex relationship.

Does S-metolachlor affect the performance of Pseudomonas sp. strain ADP as bioaugmentation bacterium for atrazine-contaminated soils?

Atrazine (ATZ) and S-metolachlor (S-MET) are two herbicides widely used, often as mixtures. The present work examined whether the presence of S-MET affects the ATZ-biodegradation activity of the bioaugmentation bacterium Pseudomonas sp. strain ADP in a crop soil. S-MET concentrations were selected for their relevance in worst-case scenarios of soil contamination by a commercial formulation containing both herbicides. At concentrations representative of application of high doses of the formulation (up to 50 µg g(-1) of soil, corresponding to a dose approximately 50× higher than the recommended field dose (RD)), the presence of pure S-MET significantly affected neither bacteria survival (~10(7) initial viable cells g(-1) of soil) nor its ATZ-mineralization activity. Consistently, biodegradation experiments, in larger soil microcosms spiked with 20× or 50 × RD of the double formulation and inoculated with the bacterium, revealed ATZ to be rapidly (in up to 5 days) and extensively (>96%) removed from the soil. During the 5 days, concentration of S-MET decreased moderately to about 60% of the initial, both in inoculated and non-inoculated microcosms. Concomitantly, an accumulation of the two metabolites S-MET ethanesulfonic acid and S-MET oxanilic acid was found. Despite the dissipation of almost all the ATZ from the treated soils, the respective eluates were still highly toxic to an aquatic microalgae species, being as toxic as those from the untreated soil. We suggest that this high toxicity may be due to the S-MET and/or its metabolites remaining in the soil.

Carcinoma Mucoepidermóide do Pulmão ­ estado da arte a propósito de um caso clínico / Mucoepidermoid carcinoma of the lung ­ state of art with regard to a case report

O Carcinoma Mucoepidermóide do Pulmão (CMP) é um tumor com baixo potencial de malignidade; acredita-se que é indolente, mas pouco se sabe sobre as suas características dada a sua baixa incidência (0,2% de todos os tumores pulmonares). Os autores apresentam um caso clínico de um Carcinoma Mucoepidermóide do Pulmão de alto grau, a que se associa, habitualmente, metastização à distância, recorrência do tumor e mau prognóstico. Destaca-se a exuberante metastização (pleural, pericárdica, ganglionar e cerebral), que contrasta com o curso da doença, relativamente indolente, volvidos 12 meses do diagnóstico. Dado não ter indicação cirúrgica, a doente foi tratada com radioterapia e quimioterapia, apesar de ainda não estar definido um tratamento standard para este tipo histológico. A raridade do diagnóstico e os escassos estudos da literatura condicionam a abordagem terapêutica sistémica destes doentes, constituindo um desafio para a comunidade médica. O possível papel da terapêutica dirigida, como os inibidores da tirosina cinase do receptor do fator de crescimento epidérmico (EGFR) ou a terapêutica contra o oncogene de fusão CRTC1-MAML2, tem sido investigado, em doentes com Carcinoma Mucoepidermóide do Pulmão de alto grau.

Mucoepidermoid Carcinoma of the Lung (MECL) is a tumor of low malignant potential; we believe it is indolent, but little is known about its clinical features because of the low incidence rate (incidence of 0.2% of all lung cancers). We present a clinical case of a high degree Mucoepidermoid carcinoma of the lung, which frequently have distant metastasis, tumor recurrence and a bad prognosis. It is highlighted in this case the exuberant metastases (pleural, pericardial, cerebral, lymph nodes), contrasting with the relatively indolent course of the disease since the diagnosis (10 months ago). Our patient was treated with radiotherapy and chemotherapy, although effective treatment measures for high-grade tumors have not been established. The rarity of the diagnosis and the rare studies in the literature affect the systemic approach to these patients, becoming a challenge for the scientific community. The role of targeted therapy directed against the epidermal growth factor receptor (EGFR) and the novel fusion oncogene CRTC1-MAML2, is being investigated in high-grade tumors.

Aspergilose pulmonar necrotizante e aspergiloma pulmonar / Necrotizing pulmonary aspergillosis and pulmonary aspergilloma

A aspergilose pulmonar necrotizante ou semi-invasiva é um processo infecioso indolente, com consequente destruição do parênquima pulmonar, causado pela inalação de Aspergillus, geralmente Aspergillus fumigatus. O aspergiloma é caracterizado pelo desenvolvimento de uma bola fúngica numa cavidade pulmonar preexistente e pode ser visto em cerca de 50% dos doentes com aspergilose pulmonar necrotizante. Os autores apresentam um caso clínico de aspergilose pulmonar necrotizante e aspergiloma que, por sua gravidade clínica e coexistência de patologia pulmonar prévia grave, sem imunossupressão conhecida, ilustra as particularidades destas patologias.

Necrotizing pulmonary aspergillosis also called semi-invasive aspergillosis is an indolent, infectious and destructive process of the lung due to invasion by Aspergillus species, usually Aspergillus fumigatus. Aspergilloma (fungus ball) usually develops in a preexisting cavity in the lung and may be seen in nearly 50% of patients with Necrotizing pulmonary aspergillosis. The authors present a case report of necrotizing pulmonary aspergillosis and an aspergilloma with underlying chronic lung disease but without any known immunodeficiency, that illustrates the particularities of these diseases.